Lower urinary tract symptoms suggestive of benign prostatic obstruction: How can clinical expertise contribute to rational management?

Objective: To perform a systematic analysis of clinical expertise on treatm ent for benign prostatic hyperplasia (lower urinary tract symptoms (LUTS) s uggestive of benign prostatic obstruction (BPO)) and to investigate the use fulness of these data in further guideline development, Methods: A modified Delphi method was used to analyse the opinions of a panel of 15 European u rologists on the appropriateness of 4 common treatments for 1,152 'indicati ons' (hypothetical cases) for LUTS suggestive of BPO. Each indication consi sted of a unique combination of 9 diagnostic variables, found to be relevan t in treatment choice in previous research. The study population was restri cted to patients for whom current guide-lines do not provide clear indicati ons on the most appropriate treatment. The panellists individually rated th e appropriateness of three active treatments (surgery, alpha (1)-adrenocept or antagonists, finasteride) using a 9-point scale, all in comparison with 'watchful waiting'. Aggregate panel judgements were calculated from individ ual ratings for each indication (appropriate, inappropriate, and uncertain) . The relationship between diagnostic characteristics and panel opinions wa s analysed using logistic regression methods. The results were compared to those of an identical panel study including 12 Dutch urologists. Results: S trong agreement existed for 42.5% of the indications, while strong disagree ment was found in only 0.1%. For patients who had not previously been treat ed for LUTS, surgery was considered appropriate in 44% of the indications. For alpha (1)-adrenoceptor antagonists and finasteride these percentages we re 56 and 6 respectively. Strong contra-indications were found only for fin asteride (34%). Logistic regression analysis demonstrated consistent panel opinions, indicating a strong cumulative impact of almost all diagnostic va riables on the panel judgement 'appropriate'. The figures on appropriatenes s were highly comparable to the results of the Dutch study (overall agreeme nt 84%, kappa 0,76), A computer program was constructed to facilitate the i mplementation and evaluation of the panel recommendations in daily clinical practice. Conclusions: Given the consistency of the panel opinions, the re sults may be useful in complementing evidence-based guidelines for LUTS sug gestive of BPO in the grey area of treatment choice. Copyright (C) 2001 S. Karger AG, Basel.